Msk Dermatology · Year 2 · from Msk Dermatology

Case 1: Early Rheumatoid Arthritis with Positive Serology

Patient Presentation

Demographics: 42-year-old woman

Chief Complaint: "My hands and feet have been swollen and painful for the past three months."

History of Present Illness: The patient describes insidious onset of pain and stiffness affecting her fingers, wrists, and the balls of her feet bilaterally. She experiences significant morning stiffness that lasts approximately 2 hours and gradually improves with activity throughout the day. The symptoms have been progressive, and she now has difficulty making a fist, buttoning her clothes, and walking comfortably. She reports associated fatigue that is disproportionate to her activity level. She denies preceding trauma, infection, or new medications. She has lost 5 pounds unintentionally over the past two months.

Past Medical History:

• Hypothyroidism
• No prior joint disease

Medications:

• Levothyroxine 50 mcg daily
• Ibuprofen 400 mg twice daily (started 2 weeks ago for joint pain)

Social History:

• Accountant
• Former smoker (quit 5 years ago; 10 pack-year history)
• Occasional alcohol use

Family History:

• Sister has "lupus"
• Mother has thyroid disease

Physical Examination

• Vital Signs: BP 124/78 mmHg, HR 76 bpm, Temp 37.1C, BMI 26 kg/m2
• General: Appears fatigued, no acute distress
• Hands:
• Bilateral synovitis of MCP joints 2-4 (boggy swelling, warmth)
• Bilateral synovitis of wrist joints
• PIP joints mildly swollen bilaterally
• DIP joints normal
• Reduced grip strength
• No Heberden or Bouchard nodes
• Feet:
• Tenderness and swelling at MTP joints 2-5 bilaterally
• "Squeeze test" positive (transverse compression of MTP joints causes pain)
• Elbows: Small nodule palpated over right olecranon
• Other joints: No knee, ankle, or shoulder involvement

Workup and Results

Laboratory Studies:

Imaging:

• Hand and wrist radiographs:
• Periarticular osteopenia at MCP and PIP joints
• Soft tissue swelling
• No definite erosions yet
• Foot radiographs:
• Soft tissue swelling at MTP joints
• Early marginal erosion at 5th MTP joint

Clinical Image

Clinical photograph of hands demonstrating symmetric swelling at the metacarpophalangeal and proximal interphalangeal joints with early ulnar deviation, characteristic of rheumatoid arthritis. Source: Wikimedia Commons, CC BY-SA 3.0.

Diagnosis

Rheumatoid Arthritis (Seropositive)

2010 ACR/EULAR Classification Criteria Score:

• Joint involvement (4-10 small joints): 3 points
• Serology (high-positive RF and high-positive anti-CCP): 3 points
• Acute phase reactants (elevated ESR and CRP): 1 point
• Duration (>6 weeks): 1 point
• Total: 8 points (>=6 required for classification)

Poor Prognostic Factors Present:

• High-positive RF and anti-CCP ("double positive")
• Elevated inflammatory markers
• Early radiographic erosion (5th MTP)
• Rheumatoid nodule
• Smoking history

Treatment Plan

Initial DMARD Therapy:

1. Methotrexate: Start 15 mg PO weekly, titrate to 20-25 mg as tolerated
2. Folic acid: 1 mg daily to reduce methotrexate side effects
3. Prednisone: 10 mg daily as bridging therapy, taper over 8-12 weeks as methotrexate takes effect

Monitoring:

• CBC and CMP every 4-8 weeks during methotrexate initiation
• Hepatitis B/C screening completed (negative)
• Chest X-ray baseline (before methotrexate)

Patient Education:

• Avoid alcohol while on methotrexate
• Contraception counseling (methotrexate is teratogenic)
• Report signs of infection
• Smoking cessation counseling (improves treatment response)

Follow-up:

• Reassess disease activity (DAS28) in 8-12 weeks
• If inadequate response, consider adding biologic (TNF inhibitor or other) or switching to subcutaneous methotrexate
• Target: Remission (DAS28 <2.6) or low disease activity (<3.2)

Teaching Points

1. Early diagnosis is critical: The "window of opportunity" for treatment within 3-6 months of symptom onset improves long-term outcomes
2. Double seropositivity: Patients positive for both RF and anti-CCP, particularly at high titers, have more aggressive erosive disease
3. Treat-to-target: Regular disease activity assessment with therapy adjustment to achieve remission or low disease activity
4. Methotrexate as anchor: First-line DMARD; folate supplementation reduces side effects without compromising efficacy
5. Bridging therapy: Short-term glucocorticoids provide rapid symptom relief while awaiting DMARD effect (takes weeks to months)

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